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Rural Barriers: Healthy Lifestyles Program, Using Diabetes as a Model. Diane Spokus Doctoral Candidate The Pennsylvania State University Workforce Education/Training & Development. Background. PEPPI ACTIVE AHEC Continuing Professional Development Programs/Health Education

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rural barriers healthy lifestyles program using diabetes as a model

Rural Barriers: Healthy Lifestyles Program, Using Diabetes as a Model

Diane Spokus

Doctoral Candidate

The Pennsylvania State University

Workforce Education/Training & Development

  • AHEC
      • Continuing Professional Development Programs/Health Education
  • Adult Aging & Development/Biobehavioral Health
  • Hartford Foundation (
  • Retaining, Managing & Retraining Older Workers
Americans’ use of information technologies has grown in many locations including the workplace, the schools, the home but not as rapidly in lower-income housing and retirement residences or church organizations where older adults congregate.
healthy lifestyles program sponsored by
Healthy Lifestyles Program Sponsored By
  • The Division of Endocrinology of
  • The Department of Internal Medicine and the
  • Department of Family and Community Medicine
  • Pennsylvania State University College of Medicine and
  • Pennsylvania Area Health Education Centers (AHEC)
  • Sponsored by:
  • Diabetes Control Program
  • Pennsylvania Department of Health
ahec mission

The mission of the Pennsylvania AHEC Program is to help communities meet their primary health care needs

needs local solutions
  • Each underserved community & individual has a different set of

needs that

must be

identified andaddressed.

goal today
Goal Today
  • To discuss the opportunities for improvement in the delivery of community-based health education programs for older adults living in rural areas.
objectives today
Objectives Today
  • To discuss the Healthy Lifestyles Program
  • To examine rural barriers to success in implementing community-based programs for older adults
  • To identify the physiological differences

that occur in the aging process that require adaptive technology

objectives of the healthy lifestyle program
Objectives of the Healthy Lifestyle Program
  • Increase the awareness of the population in the area that everyone is at risk for a chronic disease
  • Develop and implement a community training program to empower the target audience with tools to improve their lifestyles
  • Evaluate the training program through a pre- and post-trainee assessment
target audience
Target Audience
  • Older adults in low-income hi-rises, retirement communities, long-term care, assisted care facilities, church groups, and Pennsylvania Department of Aging Area Agencies on Aging.
  • Increased need in communities to obtain free community-based health education programs.
risk factors
Risk Factors
  • Overweight
    • Older population is at greater risk for obesity-related health conditions such as hypertension, diabetes mellitus and hyperlipidemia.
  • Two major factors behind obesity include
    • Inactivity
    • Poor dietary habits
  • 45 years of age or older
  • Inactive lifestyle
  • Woman having had a child weighing 9 pounds or more
  • Family history of diabetes
physical activity
Physical Activity
  • Regular physical activity
    • for older adults can have an enormous effect on their independence level and quality of life.
  • Older adults at a greater risk for developing chronic diseases
    • such as diabetes, heart disease, or hypertension
  • Motivation
    • is the key to maintaining an active lifestyle
number of people with diabetes
Number of People with Diabetes
  • United States 13 million
  • Pennsylvania 660,000

People with diabetes that do not know it:

  • United States 5.2 Million
  • In 1992 – 30 million persons over 65
  • In 2000 – 34 million persons over 65
  • About 5%, or over 1 million will be residents of an institution
  • Most older men are married; most older women are widowed
  • 86% suffer from one or more chronic health conditions
  • > age 65, 23% limited in their activities of daily living

Source: National Center for Health Statistics. (1992). Facts about older Americans. Washington, DC: Author

  • People > age 65
    • hospitalized twice as often as people under 65
  • People > age 65
    • hospital visits average 50% longer
  • People > age 65
    • use twice as many prescriptions.
  • Fastest U. S. growing population
    • > age 85

Source: National Center for Health Statistics. (1992). Facts about older Americans. Washington, DC: Author

healthy lifestyles program using diabetes as a model
Healthy Lifestyles Program, Using Diabetes as a Model

Train-the-Trainer Program

  • Volunteers from the community who attend two-hour interactive training programs on how to facilitate the Healthy Lifestyles Program
  • Recruited from organizations, parish ministries and health professions students wishing to do community work.
area agencies on aging
Area Agencies on Aging
  • Implement various programs for older Pennsylvanians.
  • 52 such Pennsylvania offices
  • Serving all 67 counties
  • Staffed with caseworkers skilled in such areas as geriatrics, social work and community resources
  • Assist older adults with questions
    • regarding nursing facilities
    • community services in nursing facility placement,
    • and a wide range of other community services tailored to your specific needs.
program timeline
Program Timeline
  • Summary reports to Department of Health every 12 months
    • Under Pennsylvania Department of Health contract to implement 16 programs per year.
  • First Month:
    • Coordinator identified sites for courses
  • Second Month:
    • The first trainee program for Facilitators held at College of Medicine.
  • The Third Month:
    • Advertisement began for course participants and continued throughout the remaining months.
    • Notices in church bulletins, newspapers, Area Agencies on Aging, Retiree residences, low-income housing.
    • First courses implemented
    • Provided exercise and nutrition books as incentives
  • Provide a one-time only follow-up session between one to two months to provide support to the individuals.
  • Also, link individuals to community resources
results from june 2002 to july 2004
Results From June, 2002 to July, 2004
  • Number of Train-the-Trainer Programs 6
    • June 4, 2002 – 4
    • June 11, 2002 – 10
    • July 2, 2002 – 8
    • July 9, 2002 – 2
    • September 26, 2002 - 14
    • July 23, 2003 - 5
  • Number of Trainees 43
      • who have participated in trainer program
  • From June, 2002 to July 1, 2004
    • 66 Healthy Lifestyle Programs conducted
    • 887 individuals participated
      • particularly lower socio-economic groups, including minorities participated


Due to facilitator attrition, we could only depend on 5 new facilitators and 2 seasoned facilitators, including myself for community-based programs.

  • Reasons: Volunteer facilitators had good intentions; however, when programs are held during the day, there are work conflicts
  • In-Kind Contributions – approximately $17,000
  • Pre-post tests and follow-up questionnaires/surveys were used to determine how many people were able to change at least one unhealthy behavior and how much physical activity changed as a result of the educational program
pre post test questions
Pre/Post Test Questions

Likert Scale (1 Disagree to 5 Agree)

  • This program gave me information that I did not know before.
  • I learned how to live a healthy lifestyle.
  • I am more aware of the risk factors of diabetes.
  • I can name one healthy eating guideline that I can follow.
  • I can name one way I can increase my activity level.
  • I can understand the importance of using the wallet card.
  • I would recommend this program to my friends, family and people I meet.
  • I was able to understand the material presented.
facilitator s evaluation questions
Facilitator’s Evaluation Questions
  • Is the program written at an appropriate reading level for the general public?
  • Is the content appropriate for the general public?
  • Does the content provided achieve the stated objectives?
  • What suggestion do you have to change the content of the program?
  • What suggestions do you have in presenting the material?
  • Is the Trainer’s Manual complete enough to give the trainer enough information to address the audiences concerns?
facilitator evaluations cont d
Facilitator Evaluations (cont’d.)
  • If the audience has questions, that the trainer cannot answer, should they:
    • Contact the people that trained them?
    • Refer them to an educator in the area?
    • Refer them to their provider?
    • Leave it up to the discretion of the trainer?
    • Other (specify)_____________________
    • Do you have any other suggestions or comments about the program?
  • Lack of funding for successful delivery of rural health education program
  • Educational level (reading level, verbal abililty)
  • Race and ethnicity (language barriers); need for more Spanish-speaking facilitators
  • Income (inability to afford hearing aids, glasses)
  • Health (age-related declines)
observations in the field
Observations in the Field
  • Cognitive difficulties in completing some simple pre/post test questions
  • Need for material for various educational levels which may be accomplished through adaptive technology
  • Increased lay person training in use of medical devices such as infusion pumps, blood pressure monitors, etc.
  • Medications not taken properly (instructions too quick to grasp)
  • Hearing losses provided a challenged in giving directions; battery-operated hearing aid transistors would have helped participants more actively participate
  • Visual problems – although we had packets in large print, there was a need for technology in the field to present the material in different modalities, such as PowerPoint, microphone, virtual presentations, etc.
  • Stimulate an increase in funding to provide computer and internet capabilities to community-based organizations that service older adults.
  • Related to the above, increase the use of technology particularly to Area Agencies on Aging, retirement communities and low-income hi-rises that service older adults.
  • Facilitate health care delivery communication in different formats that attracts different educational levels and compensates for age-related changes. This would include keeping an audience motivated through animation, video, and experiential tasks. Older adults may need to learn something new through several modalities: seeing it, hearing it and doing it.
  • Build partnerships to avoid duplication of services
  • Provide technology training to facilitators as well as to participants
age related changes
Age-Related Changes
  • Vision
      • Lens yellows and thickens
      • Muscles controlling pupil size weaken
      • Result – need for additional light
          • >65 years old →2x as much light as younger Lens person
      • Lens grows unevenly → glare
      • Color perception → pastels look alike; darker colors indistinguishable
      • Cataracts → cataract glasses thick to compensate for the lack of a natural lens
      • Macular Degeneration → central vision loss

Richman, N., & Glantz, C. (1992a). Sensory deficits and ways to help. Unpublished

Manuscript. Riverwoods, IL: Rehabilitation Associates.

ways to help
Ways to Help
  • Use non-verbal feedback through touch to compensate for visual deficits—can’t see those warm smiles
  • Adjust shade, tablecloths, curtains to avoid glare
  • Sunglasses, hats
  • Provide adequate lighting
  • Color coding doesn’t help in taking meds; contrast colors
  • Gradual lighting helps; e.g., night lights
  • Reassure them of their appearance
  • Finger foods

Richman, N., & Glantz, C. (1992a). Sensory deficits and ways to help. Unpublished

Manuscript. Riverwoods, IL: Rehabilitation Associates.

normal aging
Normal Aging


  • Presbycusis →  for men
  • Hearing worse at high frequency; sounds distorted
  • Loss  for consonants than vowels. S,Z,T,F, and G sounds difficult to discriminate
  • ↓ Well-being, paranoid reactions common
  • Important for communication & safety

Richman, N., & Glantz, C. (1992a). Sensory deficits and ways to help. Unpublished

Manuscript. Riverwoods, IL: Rehabilitation Associates.

ways to help1
Ways to Help
  • Provide amplifiers to older adults when doing community-based program
  • Overall program evaluations are not always credible when you have individuals filling out pre/post test forms who can’t hear directions, etc.
normal aging1
Normal Aging
  • Neurological Changes
    • Instructions and information on disease may be too complex
    • 7% ↓in brain size; nerve cells lost
    • Older adults earn ↓ scores compared to young
    • Age differences represent decline in ability tested or  cautiousness of individual ↓speed of processing
      • Exaggerates declines in memory and learning
    • Less willing to “guess”
    •  long term memory when instructed to organize material in brain for processing & storage
    • Recall, recognition & mneumonics— “tricks of the trade”

Richman, N., & Glantz, C. (1992a). Sensory deficits and ways to help. Unpublished

Manuscript. Riverwoods, IL: Rehabilitation Associates.

healthy lifestyles participant manual
Healthy Lifestyles Participant Manual

What is Diabetes?

  • It is a serious, chronic disease in which you have a high blood sugar level due to a lack of insulin
  • Insulin is needed to take the glucose (sugar out of the bloodstream and move it into the body’s cells to use for energy
what is diabetes
What is Diabetes?
  • It is a serious, chronic disease in which you have a highblood sugar level due to a lack of insulin
  • Insulin is needed to take the glucose(sugar) out of the bloodstream and move it into the body’s cells to use for energy
risk factors1
Type 1



Environmental (virus)

Type 2

Family members with Type 2 diabetes

Being overweight

Physically inactive

Dietary intake

Advancing Age

Ethnicity (Race)

Risk Factors
types of diabetes
Types of Diabetes
  • Type 1Type 2
    • No InsulinNot enough insulin produced

producedBody unable to use insulin


signs and symptoms of diabetes
Type 1

Frequent urination

Very thirsty/hunger

Feeling very tired

Blurred vision

Unexplained weight loss

Type 2

Frequent urination

Very hungry/thirsty

Feeling very tired

Blurred vision

Slow healing cuts

Frequent infections

No symptoms at all

Signs and Symptoms of Diabetes
what happens when you eat
What Happens When You Eat
  • Cells in your body need sugars and starches for energy to do their job
  • Food you eat is turned into sugar and starches by the stomach
  • Sugars and starches are carried in the bloodstream to the cells
  • The pancreas makes more insulin – the key- that opens the doors of the cells so the sugar goes into the cell
  • The liver is a store house for sugar. The cells, not getting enough sugar send a message to the brain. “We need sugar to do our jobs!”
  • The brain tells the liver to release stored sugar-so the cells have their energy
  • But this also increase the sugar in the bloodstream
  • And, Muscles cells may not have as many doors to be opened by the insulin – the sugar is there, but still cannot be used by the muscles
  • And again the sugar stays in the bloodstream
type 2 diabetes
Type 2 Diabetes
  • Pancreas
    • Not making enough insulin
  • Liver
    • Releases stored sugar
  • Muscle
    • Not enough doors to be opened
  • And Sugar cannot enter the cell
healthy lifestyles
Healthy Lifestyles
  • And, if you have diabetes:
  • Check blood sugar as directed by your health care provider
  • If you take insulin, check blood sugar before, during, after exercise
  • Be prepared for low blood sugar (shaky, sweaty)
  • Always wear some form of identification
diabetes management tools
Diabetes Management Tools
  • Meal Plan – balanced diet
  • Activity – increase exercise
  • Medication – Pills (Are not Insulin)
    • There is not one pill for everyone
    • People and pills are all different
  • Medication – Insulin injection provides the key
    • If pills are not enough, insulin may be subscribed
Type 1

Insulin shots

Healthy diet

Physical activity

Type 2

Healthy diet

Physical activity

Weight loss

Diabetes pills, insulin, or both, if necessary

complications of diabetes
Complications of Diabetes
  • Eye Damage
    • Blindness
  • Increased risk for heart attack and strokes
  • Kidney damage
  • Nerve damage
  • Foot ulcers/impaired wound healing
    • Amputations
lifestyle changes
Lifestyle Changes
  • Healthy diet
  • Physical Activity
  • Stop Smoking
  • Reduce Stress
what is hypoglycemia
What is Hypoglycemia?
  • Low blood sugar level
  • Causes
    • Too little food to eat
    • Too much insulin or medicines
    • Extra physical activity
  • Symptoms
    • Shaking
    • Sweating
    • Weak/Tired
    • Hunger
    • Fast Heartbeat
    • Blurry Vision
    • Headache
    • Irritable
    • Dizzy
how to treat low blood sugar
Follow your facility’s protocols

Treat with 15 gm of carbohydrates if awake:

Regular soda- ½ cup

Fruit juice- ½ cup

Glucose tablets- 3 to4

Hard candy

If symptoms remain:

Retreat with 15 gm of carbohydrates

Once symptoms go away give light snack or meal in the next 30 minutes.


½ peanut butter or meat sandwich


½ glass milk

How To Treat Low Blood Sugar
eat a variety of food
Eat A Variety of Food

Thumb =

1 OZ of


Fist =

1 Cup of


Deck of Cards =

3 OZ. of Meat

activity benefits us all
Activity Benefits Us All
  • Lowers and controls weight
  • Prevents heart disease
  • Builds strong bones and muscles
  • Controls blood pressure
reduces stress
Reduces Stress

And for those with diabetes,

Lowers blood Sugar



ways to help2
Ways to Help
  • Studies indicate mental activity helps—”Use it or Lose it”
  • Exercise daily, eliminate caffeine, play soft music
how to treat high blood sugar
How To TreatHigh Blood Sugar
  • Follow your facility’s protocol
  • Follow directions provided by doctor
  • Give fluids without sugar if able to swallow
    • Such as:
      • Diet drinks
      • Broth
      • Ice Chips
      • Water
  • When we are more active, our cells need more energy
  • So, as we increase our activity, our cells burn more sugar – lowering the sugar in our bloodstream
    • Park further away from the front of the door
    • Don’t “be dropped off” while the car is being parked
    • Take the steps
    • Push a lawn mower, don’t ride
    • Shovel snow – don’t snow throw
    • Rake leaves – don’t blow
    • Work in your flower bed
ways to help3
Ways to Help
  • Weight-bearing exercise
  • Walking
  • Running
  • medications
ways to help4
Ways to Help
  •  Calcium
  • Medications
  • Weight-bearing exercise
  • Hip pads to reduce fractures
getting started
Getting Started





general guidelines
General Guidelines
  • Start Slow and Increase Slowly
  • Warm up and cool down for 5 – 10 minutes by stretching
  • Drink plenty of water before and during your activity
  • It’s best to wait 60 -90 minutes after a meal before exercising
healthy lifestyles1
Healthy Lifestyles
  • Wear shoes that fit and socks – they prevent blisters
  • (People with diabetes are more at risk for foot problems)
  • Exercise regularly at the same time every day

It becomes a habit

foot care

Look at feet daily

Wash feet daily

Use lukewarm water

Keep skin soft

Dry feet well

Check shoes before putting on

Always wear socks

Keep feet warm and dry


Walk barefoot

Use heating pads/hot water bottles

Wear tight socks or knee highs

Wear socks with holes

Wear torn or tight shoes

Foot Care